End of Term Review of the NSP 2007-2011
Final Report
4 November, 2011
Submitted by: Mark Colvin
Submitted to: South African National AIDS Council
Acknowledgements
We would like to extend thanks to the following individuals:
SANAC Plenary: Deputy President Kgalema Motlante, Plenary Chair; Mark Heywood, Co-chair; and all Plenary members.
SANAC PIC: Co-Chairs, Precious Matsoso and Helen Rees; and all PIC members.
Department of Correctional Services: Kosie Ferreira and Roeleen Booi.
Department of Health: Yogan Pillay, Thobile Mbengashe,M. Vusil and Nhlanhla Ntuli.
Department of Labour: EHWP: Sulette Roussouw.
Department for Public Service and Administration: Morero Leseka, Sipho Senabe and Tebogo Monye.
Department of Social Development: Connie Kganakga,Johanna De Beer, Malega Kganakga andOlivia Machusi.
Department of Basic Education:Faith Kumalo, Saadhna Panday, Albertina Dano and Hersheela Narsee.
Provincial Government Coordination Structures and Representatives.
Gauteng Provincial GovernmentFrancis Akpan
Médecins Sans Frontières: Ariane Bauernfeind, Donela Besada, Lynne Wilkinson and Rebecca Hodes.
GIZ: Ingrid Obery and Asta Rau.
HEARD-UKZN: Managa Pillay.
Irish AID: Tamara Mathebula.
Italian Cooperation: Stephen Hendricks (University of Pretoria).
SANAC: Zwoitwaho Nevhutalu, Junaid Seedat, Lucie Bar-David, and Tsakani Mtileni.
SIDA: Jackie Sallet.
AFSA and Futures Group: Charles Dalton.
SANAC/GIZ: Maren Lieberum.
SANAC/HLSP: Mariam Sibanda.
CHAI: Celicia Serenata.
UNAIDS: Miriam Chipimo, Henry Damisoni,Nkhensani Mathabathe and Alasdair Reid.
Soul City: IHDC: S Goldstein.
UNFPA: Gerrit Maritz.
USAID: Rose Mulumba (Futures Group, Philip Browne, Ian Ralph (Right to Care), Zodwa Ngobese (MATCH).
US CDC: Sara Hersey.
Office of the Deputy President’s Office: Dr Nono Simelela.
All other roleplayers and stakeholders involved with the 2012-2016 NSP and 2007 – 2011 consultation process.
Abbreviations/Acronyms
AIDSAcquired Immune Deficiency Syndrome
ARTAntiretroviral treatment/therapy
ARVAntiretroviral
AZTAzidothymidine
CDWCommunity Development Workers
CHHChild-headed households
CPTCotrimoxazole prophylaxis
CSOCivil society organisation
DHISDistrict Health Information System
DoHDepartment of Health
DSDDepartment of Social Development
HAARTHighly active antiretroviral treatment/therapy
HCBCHome and community-based care
HCPHIV communication programme
HCTHIV counselling and testing
HIVHuman Immunodeficiency Virus
HTAHigh Transmission Area
IDCInterdepartmental committee on HIV&AIDS
IDUIntravenous drug use/users
KYEKnow your epidemic
KYRKnow your response
LACLocal AIDS Council
LGBTLesbian, gay, bisexual and transsexual persons
M&EMonitoring and Evaluation
MARPSMost-at-risk populations
MCPMultiple and concurrent sexual partnerships
MDR-TBMulti drug-resistant tuberculosis
MMCMedical male circumcision
MPSAMinistry of Public Service and Administration
MSMMen who have sex with men
NDoHNational Department of Health
NGONon-governmental organisation
NPONot-for profit organisation
NSPNational Strategic Plan
NVPNevirapine
NWNorth WestProvince
NWDoENorth West Province Department of Education
NWDoHNorth West Province Department of Health
NWDSDNorth West Province Department of Social Development
NWPAC North West Provincial AIDS Council
OVCOrphans and vulnerable children
PDPHCExpanded Partnership for the Delivery of Primary Health Care
PEPPost-exposure prophylaxis
PICProgramme Implementation Committee of SANAC
PLHAPeople living with HIV/AIDS
PMTCTPrevention of mother-to-child transmission
PSPProvincial Strategic Plan
RHRUReproductive Health Research Unit
SABCOHASouth African Business Coalition on HIV & AIDS
SANACSouth African National AIDS Council
SBCCSocial and behaviour change communication
SMTEmployee Health and Wellness Management Systems Monitoring Tool
SRHSexual and reproductive health
STISexually transmitted infection
TBTuberculosis
UNGASSUnited Nations General Assembly Special Session on HIV/AIDS
XDR-TBExtensively/extreme drug-resistant tuberculosis
Contents
Acknowledgements
Abbreviations/Acronyms
Contents
Executive Summary
Background
Methods used to review the NSP 2007-2011
Review of the NSP 2007-2011
Pillar 1: Prevention
Pillar 2: Treatment, care and mitigation
Conclusion: Summary of highlights and challenges with resulting recommendations
Conclusion
Achievement Highlights of the NSP 2007-2011
Key Challenges of the NSP 2007-2011
Recommendations
Review Background
Review Objectives
Methods used to review the NSP 2007-2011
Desktop Review
Provincial Reviews
Strengths and Limitations of the Provincial Review Process
Strengths
Limitations
Review of Government Sector
Overview of the NSP 2007-2011
The Policy Environment
Management, Coordination and Institutional Arrangements – National to Local
Background
The Integrated Support Team review of health overspending and macro-assessment of the public health system in South Africa
The South African National AIDS Council
The Provincial AIDS Councils
District and Local AIDS Councils
Ward Based Community Competency Programmes
Outcomes of Community Dialogues
Government Response
The Department of Public Service and Administration’s Systems Monitoring Tool Report
Department of Social Development
The Department of Basic Education
Department of Correctional Services (DCS)
Review Pillar 1: Prevention
Introduction
Prevention priority area 1: Reduce vulnerability to HIV infection and the impact of AIDS
Prevention priority area 2: Reduce sexual transmission of HIV
Multiple and Concurrent Partnerships
Age of Sexual Debut
Medical Male Circumcision
Provincial Perspectives
Condom Distribution and Usage
Key Populations
Key points about the NSP 2007-2011 in relation to Key Populations
Long Distance Truck Drivers
Prevention priority area 3: Prevention of Mother to Child Transmission (PMTCT)
Introduction
Provincial Perspectives
Prevention priority area 4: Minimize the risk of HIV transmission through blood and blood products
Review Pillar 2: Treatment, care and mitigation
Introduction
Treatment, care and mitigation priority area 1: Increase coverage to voluntary testing and promote regular HIV testing
HIV Counselling and Testing
Treatment, care and mitigation priority area 2: Enable people living with HIV to lead healthy and productive lives
Treatment, care and mitigation priority area 4: Mitigate the impacts of HIV and AIDS and create an enabling social environment for care treatment and support
Review Pillar 3: Monitoring, research and surveillance
Introduction
Provincial Perspectives
Monitoring, research and surveillance priority area 1: Implement the monitoring and evaluation framework of the NSP
Monitoring, research and surveillance priority area 2: Support the development of prevention technologies
Monitoring, research and surveillance priority area 4: Conduct policy research
Monitoring, research and surveillance priority area 5: Conduct regular surveillance
Review Pillar 4: Human Rights and Access to Justice
Introduction
Provincial Perspectives
Stigma Reduction
Reducing vulnerability to sexual and gender based violence
References
Appendix 1: Recent Policy Initiatives in South Africa
Appendix 2:
Appendix 3: Proposal for a Standardised Structure for Provincial Reviews
Appendix 4: List of Key Indicators for the Provincial Reviews
Appendix 5: Strengths and Limitations of the Provincial Review Process
Strengths
Limitations
Appendix 6. Table from page 6 of the SANAC strategic review (Dalton, 2010)
Executive Summary
Background
The purpose of this review of the National Strategic Plan (NSP) and the Provincial Strategic Plans (PSPs) 2007-2011 is to contribute to the evidence base to inform the development of the next round of strategic plans. It consists of an assessment of the achievements, challenges, missed opportunities and emerging issues to prioritise in addition to documenting lessons learnt and good practices.
Methods used to review the NSP 2007-2011
The Terms of Reference for this review required anassessment of NSP implementation by consolidating the following:
- A desk review on NSP implementation at national level.
- The 9 provincial reviews of the NSP/PSPs 2007-2011.
- Analysing data from programme and governance review tools.
- Incorporating data from the community dialogues.
Sourcing information for the review has been a challenge (please refer to specific challenges relating to M&E). We specifically thank each Province for preparation and submission of their own reviews and the following Departments for their detailed information provision: NDOH; NDSD; NDCS; NDBE.
The document has been broadly discussed through SANAC structures and PIC members were invited to submit final input and comment to aid completion.
At the time of preparing the final report, the Sector Audit report had not been signed off. However, cognisance has been made in this document using the draft findings. It is recommended that when available, the final Sector Audit Report is read in conjunction with this paper.
Review of the NSP 2007-2011
Pillar 1: Prevention
The primary aim of the NSP was to reduce the number of new HIV infections by 50%, with a particular emphasis on reducing new infections in the 15-24 year old age group.
In 2007 HIV incidence was estimated at 1.3%. To reach the NSP target, the HIV incidence in 2011 would have to be reduced to 0.65%. In 2009, the incidence in the population aged 15 years and above was estimated at 1.2%. This suggests that while strong in-roads have been made in reducing new adult infection (total annual new cases of HIV infection dropped from 640000 in 2000 to 390000 in 2009), the NSP target has not been reached.
Prevention priority area 1: Reduce vulnerability to HIV infection and the impact of AIDS
This priority was meant to include “generalized national intervention strategies related to poverty reduction”. It was not practical or realistic to make the multi-sectoral HIV and AIDS programme accountable for achieving poverty reduction in the way defined in the NSP. The MTR also did not review poverty reduction or social cohesion programmes.
Prevention priority area 2: Reduce sexual transmission of HIV
Mass media, Information, Education, Communication and Behaviour Change Programmes.
There were a number of large-scale, national mass media campaignsconducted by various organisations and exposure to South Africa’s HIV prevention communication through media campaigns is high, with 80% of those surveyed knowing at least one of the initiatives[1], in particular among the 15-24 year olds age group.In spite of these initiatives, correct knowledge on the prevention of sexual transmission of HIV was lower in 2008 than in 2005in all age and sex strata except in males aged 50 or above.
Multiple and Concurrent Partnerships
There is considerable interest and debate on the importance of MCP in spreading HIV and the relative importance of concurrency versus multiple partnerships is not resolved. The National Communication Survey reported that, overall, the rate of partner acquisition was three times higher in men than in women, and highest in men aged 20-24 years (NCS 2009). Comparing multiple partner data across the five national surveys, there is some indication of an increase over time in the proportion of 16-55 year old men who reported MSPs in the past 12 months. HIV prevalence was higher in respondents reporting more sexual partners (KYE, 2011).
Age of Sexual Debut
There has been a long term trend towards earlier sexual debut amongst youth. For men and women born before 1950, median age at first sex was 20 years and for those born in the 1980s, it was 18 years (KYE, 2011). Young Africans report higher levels of sexual experience than coloured, Indian and white youth (KYE, 2011).
Medical Male Circumcision
Since the development of the NSP 2007-2011, new evidence has emerged that male circumcision can reduce HIV transmission in men by up to 60%[2] and in South Africa local researchers found the risk of HIV transmission in circumcised men was reduced by 76% with no significant increase in sexual risk-taking behaviour[3].
In 2010, South Africa instituted an aggressive roll-out of a national Medical Male Circumcision (MMC) program with the goal of reaching 80% of HIV negative men aged 15-49 (approximately 4.3 million men) by 2015. As of June 2011, almost 238 000 circumcisions had been conducted. The guidance from the UN recommends at least 5 million circumcisions would be required in South Africa as a prevention strategy to impact on new HIV infections.
Condom Distribution and Usage
The distribution of male condoms increased from 308.5 million in 2007, to 495 million in 2010 (a 60% increase). However, this translates to only 14.5 condoms per adult male per year (15-49) in 2010 against 12.7 per adult male in 2008. The number of female condoms distributed free has increased from 3.6 million in 2007 to 5 million in 2010 (a 39% increase). However, there are still widespread complaints that female condoms are not as readily available as they should be.
Condom use in South Africa has continued to increase with the percentage reporting the use of condoms in the most recent sexual encounter increasing from 35% (2005) to 62% (2008) with the highest rates amongst younger age groups.[4]Increased condom use among the youth may have contributed to the recent decline in HIV incidence in this age group. People above 50 and married people are least likely to report condom use. PLHIV who knew that they were HIV-positive were significantly more likely to use a condom than PLHIV who did not know their HIV status.
Key Populations
Globally, men who have sex with men (MSM), transgender people (TG), sex workers (SW), injecting drug users (IDU), prisoners, and migrant[5] populations have been shown to be at disproportionate risk for HIV infection.In South Africa an estimated 9.2% of all new HIV infections are related to MSM and 19.8% are related to commercial sex work.
Prejudice and moral loading has been shown to create barriers to accessing prevention, treatment, care and support – increasing vulnerability to HIV. In spite of this, there are no national programmes within the South African HIV response to address the needs of key populations.
A minimum service package for all key population groups and an extended service package of carehas been developed.
Prevention priority area 3: Prevention of Mother to Child Transmission (PMTCT)
Since 2008, South Africa has rapidly scaled-up it its PMTCT and Early Infant Diagnosis (EID) programmes. By 2010, PMTCT was offered at 98% of health facilities. Among infants exposed to HIV 83.9% received a PCR test at 6 weeks, 65.8% were given cotrimoxale at 6 weeks, and 17.8% had an HIV antibody test at approximately 18 months.
As a result of the scale up of PMTCT in South Africa, by 2010, transmission from mother to child at 6 weeks was reduced to 3.5 percent
Some of the main challenges of NSP 2007-2011 faced include the following:
- Women tend to present late at ANC.
- System failures - Retesting rates for mothers for HIV were around 29% nationally.
- Monitoring of HIV transmission rates for infants at 6, 12 and 18 months.
- Erratic social mobilisation and communication.
Prevention priority area 4: Minimize the risk of HIV transmission through blood and blood products
South Africa continues to achieve 100% targets for blood being screened in a quality assured manner. Across the almost 19,000 blood banks operated by NBTS that screened over 775,000 blood units in 2010, HIV transmission through blood has been virtually eliminated and the safety of blood products in South Africa is on par with international standards (UNGASS report, 2010).
In addition, as part of this priority area, interventions were set up to strengthen injection safety and further minimise the transmission of HIV during medical injections or through the waste generated through this procedure.
Pillar 2: Treatment, care and mitigation
The second aim of NSP 2007-2011 was to reduce the impact of HIV and AIDS on individuals, families, communities and society by expanding access to appropriate treatment, care and support to 80% of all HIV-positive people and their families by 2011.
Treatment, care and mitigation priority area 1: Increase coverage to voluntary testing and promote regular HIV testing
Coverage of HIV counselling and testing (HCT) increased substantially from 2005 to 2010. Between 2008 -2009, 96% of public health facilities in the country offered voluntary HIV counselling and testing[6](target of 100%), and 24.7% of adults had been tested and received their results in the past 12 months with a target of 11%.[7]
In April 2010, South Africa launched a national HCT campaign with the goal of promoting HIV counselling and testing and urging all South Africans to know their HIV status and be screened for TB, and other health issues. With a target of testing 15 million people by June 2011, this was the largest testing campaign ever undertaken. As of June 2011, over 14 million people were counselled and almost 13 million people had been tested for HIV as part of the HCT Campaign. In addition, South Africa is currently scaling-up its Provider Initiated Counselling and Testing (PICT) model to extend access to HCT at health facilities. The drop out of testing indicates some issues related to quality of counselling which should be addressed to ensure everyone counselled is able to access HIV testing.
Treatment, care and mitigation priority area 2: Enable people living with HIV to lead healthy and productive lives
Roll-out of antiretroviral therapy continues to be successful, with 1.4 million persons started on antiretroviral therapy and approximately 1.1 million currently on treatment. A revision of the treatment guidelines in 2009 has increased the threshold for ART treatment in pregnant women and patients co-infected with TB and HIV to CD4+ count 350, and the provision of safer and effective antiretroviral therapy regimens for adults and children.
Expanded access to treatment through primary health care and nurse-initiated antiretroviral therapy is being rolled out throughout the country. “Task-shifting” from doctor to nurse and from pharmacist to pharmacy-assistant or technician is supported by Department of Health policies but actual implementation has been slow.
The National ART Costing Model has established the expenditure framework for conditional grants for antiretroviral therapy, enabling increased access to treatment. The recent antiretroviral therapy tender negotiations (2011) have led to significant cost savings.
Overall adult mortality rates have demonstrated a gradual reduction, reflecting the increase in treatment access.
The rapid escalation of access to ART in South Africa to become the largest HIV treatment programme in the world has not been without its challenges. The absence of a national M&E plan for monitoring treatment has resulted in provinces developing their own systems. Other challenges include high levels of loss-to-follow up, inadequate adherence support, long waiting lists at some sites and the need for greater access to paediatric formulations and second-line treatment.